Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip and questions answered for families in intensive care.
So, I have an email here from Tracy and Tracy writes, “My father has had a heart attack and the hospital had him on life support. Now, they’re saying his kidneys are failing because his heart isn’t pumping much blood around his body. It’s only pumping 17% of what it should, they say. And because of this, they do not want to operate on his heart. They have now said they want to pull the plug and says nothing they can do. They are pressuring me to agree, and I want to know if they can do that. I am his power of attorney.” Great question, Tracy, and thanks for writing in.
So, couple of things here. So, obviously you’re saying that your dad had a heart attack. You’re saying his heart is only pumping at 17%. You are referring to ejection fraction here. And ejection fraction is the contractility function of the heart. It is the number on how effective the heart pumps. Now, ejection fraction ideally should be above 65 to 70%. Now, you are referring to an ejection fraction of 17%. I would assume they have done an ultrasound of the heart or an echo of the heart or a TOE, a transesophageal ultrasound, to determine his ejection fraction.
Now, with such low ejection fraction, his blood pressure would’ve probably plummeted to a point where his kidneys are failing because the kidneys weren’t perfused for a while, and that got him into kidney failure. So now, they’re saying they want to pull the plug and there’s nothing else they can do, and they’re pressuring you to agree to pull the plug. And I want to know if they can do that, and you are the power of attorney. So, let’s break this down, Tracy, for you.
The biggest challenge for families in intensive care is always that they don’t know what they don’t know. They don’t know what to look for. They don’t know what to ask. They don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. And that’s probably the biggest challenge that you’re facing with because the intensive care team wants to stay in control of the narrative. And at the moment, I can see your loss. You don’t know what questions to ask. The only avenue you can see is the avenue they’re giving you, which is to “pull the plug”, without them giving you any treatment options for your dad. Now, you haven’t shared how old your dad is, but I’ll come to age in a moment.
For someone after a heart attack in intensive care, especially with such a low ejection fraction, there are a number of treatment options. One of them, inotropes or vasopressors such as Levophed, noradrenaline, Norepinephrine, epinephrine, adrenaline, dobutamine, dopamine, milrinone, and especially milrinone and dobutamine are increasing the contractility of the heart and therefore should improve the ejection fraction. They haven’t told you that. You should also seek cardiologist input. You should be talking to a cardiologist here, not only to the intensive care team.
Now, also another drug that can be used with ejection fraction so low is Levosimendan. Again, Levosimendan is also known as a vasopressor or inotrope, and that can help with improving contractility or ejection fraction.
Now, other things that can be done depending on your dad’s age, and again, you haven’t shared your dad’s age, ECMO (Extracorporeal membrane oxygenation). If he’s going into cardiac failure or heart failure after the heart attack, he could go on ECMO. Usually, the cutoff for ECMO is around 65 years of age. You haven’t shared how old your dad is.
Next, once his ejection fraction has improved, then they might be able to take him for surgery. He probably needs cardiac surgery after the heart attack, but you should be trying to find out whether he’s a candidate for cardiac surgery once his cardiac condition has improved. And you should be finding out if he’s a candidate for ECMO. And you should also be finding out if your dad potentially is a candidate for a heart transplant. So, it’s so critically important that you take control of the narrative here and that you start asking the right questions. Intensive care teams often only tell you half of the story. I’m sure you would’ve shared with me in your email if they had given you any treatment options, but it doesn’t look like they have.
Other treatment options could be to determine cardiac output, cardiac index. Maybe he needs an intra-aortic balloon pump. An IABP or intra-aortic balloon pump that can also help with improving cardiac contractility. So, they haven’t even given you half of what’s available for you. The only option they’ve given you is “pull the plug” and you should be challenging that every step of the way. You should be asking for treatment options.
Can they force you to pull the plug? No, absolutely not. You are in control if you are the power of attorney. And unless your dad has a medical directive or an advanced care directive where it’s documented that he wouldn’t want life support in intensive care. It also sounds to me like your dad needs kidney support very soon. Maybe he needs to go on dialysis or on hemofiltration to get the kidneys back on track.
Now, if he does that on 17% of ejection fraction, there’s also a chance that he might drop his blood pressure further and then the whole range of inotropes or vasopressors might be needed but that remains to be seen if dialysis is started.
I’m not going into too much detail now with mechanical ventilation, I would assume your dad is on the ventilator, but we leave that out for now. I think until his heart has improved, he’ll be struggling to get off the ventilator. But again, seek cardiology review or cardiology input and also find out whether he’s been to the catheter lab because the catheter lab report can give you more insights about how strong or how weak his heart really is. That’s again, why you need to see cardiology input.
I hope that helps.
That is my tip for today.
If you have a loved one in intensive care, go to intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected].
Also, have a look at our membership site for families in intensive care at intensivecaresupport.org. There, you have access to me and my team, 24 hours a day, and we answer all questions intensive care related.
If you need a medical record review for your loved one while your loved one is in intensive care or after intensive care, you can contact us as well. Please note, it is so much better if we can help you review medical records while your loved one is in intensive care, rather than after intensive care. You need real time information. You need real evaluation of medical records in real time because as you’ve just seen in today’s case study, intensive care teams are not even telling you half of the things that are happening. So, you need a second opinion from day one.
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Thanks for watching.
This is Patrik Hutzel from intensivecarehotline.com and I’ll talk to you in a few days.